Intake Consent Forms – Non-Workflow Today's Date* MM slash DD slash YYYY Staff Completing Orientation* Client's CounselorChoose Counselor HereKelsey Gregg, LADCDavid Smith, MEd, LADCChoice Pickins Newstrom, ADC-TGroup Start Date: MM slash DD slash YYYY Attendance Days Select All Monday Tuesday Wednesday Thursday Friday Client DetailsClient Name* First Last Client Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female Trans/Non-Binary Client PhoneClient eMail Address:* Client Signature*Program*Make a SelectionElite EmPower WomenElite Recovery MenElite WritesUncategorizedGroup*– Fill Out Other Fields –PhoneThis field is for validation purposes and should be left unchanged.
